Surgical and pharmaceutical site access guide

ABSTRACT

An introducer guide  15  for introducing medical items into an internal tissue of a patient is provided. The guide  15  includes a cannula  20  defining a lumen sized to receive the item and a lateral opening  24.  A ramp is disposed within the lumen adjacent and inclined toward the lateral opening  24.  A hub  40 ′ is attached to the second end  22  of the cannula  20.  The hub  40 ′ includes a gripping portion  41 ′ configured to be held when inserting and positioning the introducer  15.  The gripping portion  41 ′ has a length l gp  sufficient for gripping and a tactile indicator  44  disposed along substantially the entire length l gp  of the gripping portion  41  on the hub  40 ′. The indicator  44  has a fixed angular relationship with the lateral opening  24.  The invention also includes methods for obtaining a biopsy sample and methods for treating lesions.

REFERENCE TO RELATED APPLICATIONS

This application is a continuation-in-part of U.S. Ser. No. 09/117,755,filed Aug. 04, 1998, now U.S. Pat. No. 6,203,524, nationalized from PCTApplication No. PCT/US97/02103, filed Feb. 10, 1997, which is acontinuation-in-part of Ser. No. 08/599,381, filed Feb. 09, 1996 nowU.S. Pat. No. 5,800,389.

FIELD OF THE INVENTION

The present invention broadly concerns surgical and pharmaceuticaldelivery systems. More specifically, the invention concerns biopsydevices that provide safe and efficient coaxial, cofocal and eccentricsampling or delivery with only a single guide device placement.

BACKGROUND OF THE INVENTION

In the practice of diagnostic medicine, it is often necessary ordesirable to perform a biopsy, or to sample selected tissue from aliving patient for medical evaluation. Cytological and histologicalstudies of the biopsy sample can then be performed as an aid to thediagnosis and treatment of disease. Biopsies can be useful in diagnosingand treating various forms of cancer, as well as other diseases in whicha localized area of affected tissue can be identified.

During the biopsy procedure, care is taken to minimize the physicaltrauma inflicted upon the intervening tissues that surround the affectedarea or target tissue and at the same time to protect the practitionerfrom health hazards. One typical biopsy procedure includes inserting ahollow biopsy needle through the intervening tissue into the targettissue to be sampled. The sample tissue is then harvested through theneedle by applying suction through the needle, typically with a syringe.

Other more complicated devices have been developed in an attempt toimprove biopsy procedures and results. Three references, U.S. Pat. No.5,301,684 to Ogirala; U.S. Pat. No. 5,424,376 to Banys et al.; and U.S.Pat. No. 5,224,488 to Neuffer disclose biopsy devices employing lateralopenings. The Ogirala reference shows a cutting edge on a springoperated flap over the lateral opening. The Neuffer device includes atwisted flexible cutting strip contained within the needle. Turing ahandle flexes the strip through the lateral opening. The surgeon thenrotates the device to cut a sample and guide it into the needle. TheBanys patent discloses a biopsy needle attached to a syringe having acannula which is slidable over the needle to alternately expose or coverthe lateral opening. Both the cannula and the lateral opening provide atissue cutting edge. Using the Banys device, the surgeon is required tomaneuver the needle so that the sample is placed within the needle andthen slide the cannula to cover the lateral opening and trap the samplewithin the needle.

Another reference of interest, U.S. Pat. No. 3,001,522 to Silverman,discloses a biopsy device having a pair of resilient arms which extendfrom the end of the device. The arms are disposed at an angle away fromthe axis of the device and are oppositely beveled to urge the arms apartas they are inserted into tissue. The Silverman device does not includea side port or a ramp for exit of a biopsy needle from an introducerdevice.

The prior art biopsy procedures and devices suffer from severaldisadvantages. First, they do not adequately address the need formultiple samplings. It is often desirable to sample the tissuesurrounding a lesion in addition to the lesion itself. Also, needleaspiration biopsies are prone to sampling errors, which necessitatereinsertions of the biopsy needle.

Furthermore, none of the known prior devices accommodate the need toreach behind vital organs and structures because they require a straightpath to the target. Current systems require multiple device insertionsto sample tissue eccentric to the initial needle placement.Unfortunately, multiple insertions of the biopsy device increase patientdiscomfort, surgical time and the risk of complications.

Another important consideration in biopsy needle design is that theamount of tissue harvested be sufficient for the types of analysis to bedone. Although major improvements have been made in the sensitivity oftest procedures and apparatus so that smaller samples have becomesufficient for each test, the number of different test procedures andthe importance of having the capability for redundant or confirmingtesting still necessitates having a suitable sample size. However, thesize of the tissue sample is limited by the size of the opening in thesampling end of known biopsy needles. Where the size of the tissuecollected is inadequate, multiple device insertions will be required.This is often complicated by the difficulty in returning to the exactlocation required as well as the increased trauma to the patient.

Current systems are also limited in that they cause unnecessary traumato the patient. For example, lesions located behind important vascularstructures are difficult to reach without causing damage. Also, pushinga hollow needle through intervening tissues to the target area resultsin the accumulation of unwanted tissue in the needle, which caninterfere with or complicate sample analysis. Finally, the open end of abiopsy needle or the projecting edge of a cutting cannula can tear thesurrounding tissue unnecessarily, increasing trauma to the patient.

Current systems that attempt to address some of these concerns aregenerally complicated spring-operated or multi-component devices.Furthermore, these devices require multiple insertions for samplingeccentric to the initial device placement. Accordingly, a need hasremained for biopsy devices which compensate for sampling errors andaccommodate the need for safely and efficiently obtaining multiplesamples with a single device placement.

Once pathology is diagnosed, the site must be accessed for treatment.Conventionally, malignancies are treated indirectly by chemotherapyand/or radiation or directly by removal of the lesion. Each of theseapproaches has limitations and undesirable side effects. Surgery carriesrisks of infections and adverse anesthesia effects and does not alwaysimprove the outcome. Surgery may not be an option due to patientcondition or the location and size of the tumor. Furthermore, somestudies have suggested that surgery may be associated with the spread ofsome cancers. Chemotherapy and radiotherapy affect both normal andmalignant dividing cells, leading to, for example, hair loss, nausea anddecreases in all blood cell types. In spite of the emotional andphysical costs paid, conventional treatments do not always increaselength of survival or quality of life of patients.

Percutaneous procedures are now favored for their reduced risks andtrauma. Ideally, conditions would be treated locally through a singleport instead of systematically. Such treatments would be more precise aswell as less traumatic and invasive. Various conditions have beentreated percutaneously with some success using such methods asmechanical, chemical and radio-ablation. One limitation of these knownprocedures is the accuracy of needle placement.

Transperineal radioactive seed implantation show great promise fortreating prostate cancer (Grimm et al., New Techs in Pros. Surg.2:113-126, 1994). This percutaneous, outpatient treatment provides moreprecise and effective dosing than open approaches with lower morbiditythan external beam radiation. While this procedure represents a majoradvance in treating prostate cancer, improvements are still needed inobtaining reproducible and accurate needle placements. The methodsinvolve multiple needle placements and removal. A depth reference pointmust be calculated by measuring the distance from the hub of the needlefor each placement. It is important that the needle and seed placementbe precise. Needle placements of more than 1-2 mm off the targetedcoordinate must be repositioned. Needle placements that are otherwise ontarget must be repositioned if the needle insertion causes lateralrotation of the prostate. This procedure also requires at least twosurgeons for manipulation of the needles and stylets to prevent improperdeboarding of the pellets.

Percutaneous fine-needle alcohol ablation has also been used with somesuccess in the treatment of tumors. Karstrup et al. (AJR: 154:1087-1090, 1990) disclose ablation of parathyroid tumors underultrasonographic guidance. Precise needle placement is essential due tothe important neurological and vascular structures in the area. Theauthors recommend small amounts of alcohol and precise placement of theneedle tip to avoid nerve damage.

Accordingly, there is a need for less invasive and traumatic and yetmore precise, efficient and localized treatments of lesions.

SUMMARY OF THE INVENTION

Briefly describing one aspect of the invention, there is provided asurgical and pharmaceutical site access guide device which allowscoaxial, cofocal and eccentric sampling and delivery with a singledevice placement. The invention includes an introducer device thatincludes a cannula having a first end and a second end and defining alumen. The second end of the cannula defines an aperture. The cannuladefines a lateral opening in communication with the lumen adjacent thefirst end.

The introducer devices also include a solid tip having an anatomicallydistal end secured to the first end of the cannula and a proximal endconfigured to pierce tissue. In one aspect of the invention, a ramp isdisposed within the cannula at an end of the lateral opening adjacentthe first end of the cannula. The ramp is inclined toward the lateralopening whereby the items will be deflected through the lateral openingas they are advanced within the lumen and exit the cannula.

In one specific aspect of the invention, an introducer also includes ahub attached to the second end of the cannula which includes a grippingportion configured to be held when inserting and positioning theintroducer. The hub defines a channel which is in communication with theaperture.

The invention also provides indicating means for indicating theorientation of a lateral feature. In some embodiments, the indicatingmeans includes a tactile indicator projecting from the gripping portionof the hub. In a specific embodiment, the indicator is a raised rib thathas a width less than one third of the diameter of the gripping portionand a height greater than its width. This provides a positive tactileindicator that is unmistakably sensed when the gripping portion isgrasped.

In one aspect of the invention, the introducer includes means forprotecting the practitioner from inadvertent needle sticks. In aspecific embodiment of the invention, the means includes a flange thatprojects from the hub at a location anatomically distal from thegripping portion. The flange is configured to prevent inadvertent needlesticks when a biopsy needle is inserted into the introducer.

In one specific embodiment, a biopsy needle having a bend adjacent ananatomically proximal end of the needle is provided. The bend deflectsthe proximal end of the needle at an angle away from the longitudinalaxis of the needle.

The invention also includes methods for obtaining a biopsy sample andmethods of making a guide device. According to procedures for obtaininga biopsy sample of this invention, a biopsy needle introducer of thisinvention is inserted into a patient at the biopsy site. The biopsyneedle is then inserted into the lumen of the introducer and advanceduntil the proximal end of the biopsy needle projects through the lateralopening at an angle relative to the introducer and into the biopsysample site.

In one aspect of the invention, the biopsy needle is withdrawn from thesample site and the introducer rotated. The biopsy needle is thenreinserted into the introducer and advance to obtain a second biopsysample from a location eccentric from the first biopsy sample site.

In another aspect of the invention, the introducer is rotated with theproximal end of the biopsy needle contained within the lumen. The biopsyneedle is then readvanced to eject the proximal end of the biopsy needlefrom the lumen to obtain a second biopsy sample site from a locationeccentric from the first biopsy sample site.

The invention also provides methods of making guide devices. Accordingto the methods of this invention, a hollow cannula defining a lateralopening in communication with the lumen is provided, a hub is attachedto an end of the cannula and the solid tip is secured to the cannula. Inone aspect of the invention, the securing step includes inserting an endof the tip into the first end of the cannula, crimping the cannula ontothe tip for temporary fixation and then welding the tip to the cannula.

In still another embodiment, systems are provided for diagnosing andtreating a lesion inside a body. The systems include guide devices incombination with biopsy needles, localization wires, visualizationwires, ablation means and pharmaceuticals. Advantageously, a lesion canbe biopsied and treated through a single placement of the guide device.Multiple locations of a lesion can be biopsied and treated through asingle device placement.

The invention also includes methods for delivering therapeutic items toa pathological site inside a patient's body. The methods includeinserting an introducer guide of this invention into the patient nearthe site and manipulating the cannula to position the lateral openingadjacent the site. A pharmaceutical agent such as an ablationcomposition can then be advanced through the lumen of the cannula to thesite.

Accordingly, it is an object of the invention to provide a surgical andpharmaceutical site access guide device that allows coaxial, cofocal andsampling and/or delivery to the site with a single device placement. Oneadvantage of the present invention is that it compensates for placementerrors without requiring multiple device placements. Another advantageof this invention is that it accommodates the need for obtainingmultiple samples/deliveries around a lesion or target tissue withoutrequiring multiple device placements.

Another object of the invention is to provide improved devices havingsafety features. The present invention provides means for protectingpractitioners from inadvertent needle sticks. The designs of thisinvention also decrease the trauma to the patient.

One advantage of this invention is that it provides tactile indicatormeans on the gripping portion for hubs of medical devices. The indicatormeans do not require tactile searching nor visual confirmation and thusenhance the efficiency of the procedure.

Another advantage of this invention is that it provides tools forpercutaneous procedures that are cost effective to make and relativelyeasy to use. The present invention provides simpler, more efficientoperation which may decrease surgical time and increase accuracy. Thisinvention provides elegant constructs which are less likely tomalfunction than the more complicated spring operated and/ormulti-component devices found in the prior art.

These and other objects, advantages and features are accomplishedaccording to the devices and methods of the following description of thepreferred embodiment of the present invention.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a side elevational view of a biopsy assembly according to thisinvention.

FIG. 2 is a side view of the needle introducer shown in FIG. 1 with apartial longitudinal section of the proximal end of the introducer.

FIG. 3 is an enlarged side cross-sectional view of the needle introducershown in FIG. 2.

FIG. 4 is an enlarged side cross-sectional view of the biopsy assemblyshown in FIG. 1.

FIG. 5 is an enlarged top cross-sectional view of the proximal end ofthe needle introducer shown in FIG. 2.

FIG. 6 is an end cross-sectional view of the introducer shown in FIG. 2taken along lines 6—6.

FIG. 7 is a side elevational view of the biopsy assembly shown in FIG. 1with a biopsy needle stylet in place.

FIG. 8 is a side elevational view of the introducer of FIG. 2 having anintroducer stylet in place.

FIG. 8A is a side elevational view of another embodiment of thisinvention.

FIG. 8B is a detail of the hub of the device shown in FIG. 8A.

FIG. 8C is a bottom elevational view of another embodiment of thisinvention.

FIG. 8D is a top elevational view of an end of the device shown in FIG.8C.

FIG. 8E is a side elevational view of the hub of the device shown inFIG. 8C.

FIG. 8F is a top elevational view of the hub shown in FIG. 8E.

FIG. 9 is an enlarged side cross-sectional view of the proximal end ofthe needle introducer shown in FIG. 2 with an introducer stylet inplace.

FIG. 10 is an enlarged side cross-sectional view of the proximal end ofa biopsy assembly incorporating a biopsy needle having a bend.

FIG. 11 is a side view of an introducer guide of this invention.

FIG. 12 is an enlarged side longitudinal view of the introducer shown inFIG. 11.

FIG. 13 is an enlarged longitudinal view of the introducer of FIG. 11loaded with pharmaceutical pellets.

FIG. 14 is a side elevational view of the introducer of FIG. 11 loadedwith a mechanical ablation needle.

FIG. 15 is a side elevational view of the introducer of FIG. 11 loadedwith a chemical ablation needle.

DESCRIPTION OF THE PREFERRED EMBODIMENT

For the purposes of promoting an understanding of the principles of theinvention, reference will now be made to the embodiments illustrated inthe drawings and specific language will be used to describe the same. Itwill nevertheless be understood that no limitation of the scope of theinvention is thereby intended, such alterations and furthermodifications in the illustrated devices, and such further applicationsof the principles of the invention as illustrated therein beingcontemplated as would normally occur to one skilled in the art to whichthe invention relates.

The present invention provides surgical and pharmaceutical site accessguide devices and methods for accessing locations within the body. Thisinvention is advantageous anytime it is beneficial to change thedirection or location of a device placement such as for biopsy, breastmass needle localization wire placement, ablation or radioactive seedplacement. The present invention provides many benefits such asextremely precise tissue sampling and improved safety features. Thisinvention compensates for sampling and placement errors and accommodatesthe need for obtaining multiple samples without multiple deviceplacements by converting peri-target placement into successful placementwithout repositioning the device. Devices according to this inventionalso allow the practitioner to safely reach behind important vascularstructures to obtain samples from target tissue or lesions. Hub featuresare provided that positively indicate the angular orientation of thedevice when it is inserted into tissue. The invention also protects thetissue surrounding the lesion from unnecessary trauma. Furthermore, thepresent invention also provides features which protect the practitionerfrom inadvertent needle sticks.

This invention also answers the need for improved devices and methodsfor percutaneous treatments. In one aspect, the invention provides guidedevices for locally treating a lesion within the body of a patient. Theguide devices provide less traumatic and minimally invasive yet highlyaccurate placement of therapeutic agents at a lesion. In anotherembodiment, methods are provided for accessing, diagnosing and treatinga lesion with a single guide placement. These methods significantlyreduce trauma, risk and patient inconvenience.

A biopsy device assembly 10 in accordance with one preferred embodimentof the present invention is depicted in FIG. 1. Generally, the biopsyassembly 10 includes a biopsy needle 11 and an introducer 15 which ismore clearly shown in FIG. 2. The introducer 15 includes a cannula 20having a first end 21 and a second end 22. The cannula 20 defines alumen 25 which extends between the first end 21 and the second end 22 ofthe cannula 20 as shown more clearly in FIG. 3. A tip 30 which closesthe lumen 25 is disposed at the first end 21 of the cannula 20. Thecannula 20 defines an aperture 23 at the second end 22 of the cannula20. The aperture 23 is in communication with the lumen 25 and is sizedand configured to receive a biopsy needle 11 for passage into the lumen.

The cannula 20 also defines a lateral opening 24 which is incommunication with the lumen 25. The lateral opening 24 is preferablyadjacent the first end 21 of the cannula 20. The lateral opening 24 issized and configured to allow exit of a biopsy needle from the cannulaas it is advanced through the lumen 25.

The lateral opening 24 allows the practitioner to sample multiple areaswithin a sampling zone defined around the introducer 15. The introducer15 can be rotated so that the lateral opening 24 will be exposed todifferent areas within the sampling zone, so that a biopsy needle 11 canbe directed into these different areas. In this way, a single placementof the biopsy device, or introducer, provides cofocal and eccentricsampling as well as coaxial sampling. Typical biopsy needles allowcoaxial sampling by varying the depth of the needle placement butrequire additional device placements for cofocal or eccentric sampling.This invention, on the other hand, allows the practitioner to return tothe precise location within the target tissue with a second biopsyneedle by leaving the introducer in place.

As shown in FIGS. 3-5, the introducer 15 preferably includes a ramp 35disposed within the cannula 20 at an end 36 of the lateral opening 24adjacent the first end 21 of the cannula 20. The ramp 35 is inclinedtoward the lateral opening 24. In the operation of the biopsy assembly10, a biopsy needle 11 will be deflected through the lateral opening 24as it is advanced through the lumen 25 and exits the cannula 20. Theramp 35 provides controlled exit of the biopsy needle 11. The slope ofthe ramp may be altered to obtain a desired angle of deflection of theneedle 11 as it exits the lateral opening 24.

In a preferred embodiment, the solid tip 30 is preferably a separatecomponent which is secured to the first end 21 of the cannula 20 asshown in FIGS. 2-5. The anatomically distal end 31 of the tip 30 can besecured to the cannula 20 using any suitable means. The tip 30 includesa shaft 33 extending between the distal end 31 and the proximal end 32.The tip 30 also includes an anatomically proximal end 32 which isconfigured to pierce tissue. The proximal end 32 preferably extendsbeyond the first end 21 of the cannula 20. The solid tip 30 can beprovided in any length which suits the particular application. Varyingthe length of the solid tip varies the distance from the proximal end 32to the lateral opening 24 and from the proximal end 32 of the tip 30 tothe proximal end of the needle 11.

It is contemplated that the proximal end 32 has a configuration that issuited for the particular tissue to be sampled. For example, the tip maybe beveled. In one embodiment, the tip has a trocar geometry. Themultiple bevels of the trocar tip are useful in combination with ahigher gage cannula for use in denser tissue. In one specificembodiment, a trocar tip is used with an 18 gage cannula. A single bevelis useful in combination with a thinner gage cannula for applicationswhich require steering or for use in less dense tissue. For example,sampling lymph node tissue generally requires a smaller gage cannula,and consequently is better served by a single bevel tip.

Turning back to the distal end 31 of the tip 30, this end is preferablysloped to form the ramp 35. In a specific embodiment, as shown moreclearly in FIG. 3, a portion 34 of the shaft 33 extends slightly intothe lateral opening 24. This provides a smooth exit of the biopsy needle11 through the lateral opening 24 and prevents catching of the needle 11on the cannula 20 near the edge of the lateral opening 24.

Preferably, the distal end 31 of the tip 30 has an outer diameter D_(i)which is smaller than an inner diameter D_(c), of the first end 21 ofthe cannula 20. The distal end 31 of the tip 30 is then at leastpartially disposed within the lumen 25 at the first end of the cannula20. The tip 30 can be secured to the cannula 20 by an interference fit.Preferably, the cannula 20 is crimped onto the solid tip 30 to hold thetip in the desired position within the cannula while the tip is laserwelded to the cannula. It is contemplated that the cannula 20 can alsobe secured to the tip 30 by any other suitable means including anadhesive.

In a preferred embodiment, the invention includes a hub 40 attached tothe second end 22 of the cannula 20 as depicted in FIG. 2. Referringalso to FIG. 6, hub 40 defines a channel 45 for delivering a biopsyneedle to the cannula 20. The channel 45 includes a first end 46 and asecond end 47. The first end 46 of the channel 45 surrounds the secondend 22 of the cannula 20 and is in communication with the aperture 23.The channel 45 of the hub 40 is preferably funnel shaped as shown inFIGS. 2 and 6. The first end 46 of the channel 45 has an interior radiusR, that is smaller than the interior radius R₂ of the second end 47 ofthe channel 45. The channel 45 tapers from the second end 47 of thechannel 45 to the first end 46 of the channel 45 to guide a biopsyneedle from the hub 40 to the lumen 25 of the cannula 20.

The hub 40 also preferably includes a fitting end 43 adjacent the secondend of the channel. The fitting end 43 is configured for engagement witha stylet or a syringe. It is contemplated that the fitting end 43 willbe of any suitable configuration including, but not limited to, a Luer®fitting.

The hub 40 preferably includes a gripping portion 41 as shown in FIG. 2.The gripping portion 41 is configured to be held by the practitionerduring insertion and positioning of the introducer 19 and has a lengthl_(gp) sufficient for manual gripping by the surgeon. In someembodiments, the gripping portion 41 is provided with tactile indicatormeans. The indicator means is in a fixed angular relationship with afeature laterally disposed on the sidewall 20a of the cannula 20, suchas the lateral opening 24. In other words, the hub 40′ cannot rotaterelative to the cannula 20.

In preferred embodiments, the invention provides positive indicatormeans for positively indicating the angular orientation of a lateralfeature of the introducer. The positive indicator means is impossible tomiss when the surgeon is gripping the gripping portion of the hub duringuse of the instrument. The positive indicator means allows use of thedevice without the need for tactically searching for the indicator norvisual confirmation of the orientation of the lateral feature. Forexample, by merely holding the gripping portion, the surgeon instantlyand continuously knows the direction of the lateral opening 24 althoughthe lateral opening 24 is hidden within tissue.

In one embodiment shown in FIGS. 7 and 8, the indicator means includes asmooth, uninterrupted flattened portion 42 on the otherwise cylindricalgripping portion 41 of the hub 40. The flat 42 provides a tactilereference point for the location of the lateral opening 24. The flat 42also provides the practitioner with a more stable grip on the hub 40.Preferably the flat 42 is oriented on the same side of the cannula 20 asthe lateral opening 24; however any orientation is contemplated as longas it indicates the relative position of the lateral opening 24. Theflat 42 preferably has a length l_(f) that is at least about one half ofthe length l_(gp) of the gripping portion 41 and a width substantiallyequal to the diameter D_(gp) of the portion 41. Preferably, flat 42 hasa length l_(f) that is nearly equal to the length l_(gp).

Preferably, the device will include positive indicator means. Thepositive indicator means of this invention includes a raised tactileindicator, such as the one depicted in FIG. 8A, for example. Thepositive indicators of the present invention have dimensions relative tothe gripping portion on the hub such that the indicators projectblatantly from the gripping portion. In order to provide positiveindication, the tactile indicators are disposed along at least about onethird of the length l_(gp) of the gripping portion 41′ of the hub. Theindicators also have a width W less than about a third of the diameterD_(gp) of the gripping portion 41 of the hub 40′ and a peak height Hgreater than about the width W. This feature makes the indicatorimpossible to miss when the surgeon is operating the introducer. Thesurgeon is not required to stop or pause the procedure to search for atactile reference on the hub or visualize the orientation of theintroducer.

In the embodiment depicted in FIGS. 8A and 8B, the introducer 15 isfitted with a hub 40′ with raised tactile indicator 44, which has afixed angular relationship to the lateral opening 24 of the cannula 20.In a preferred form as shown in the figures, the indicator 44 is araised rounded rib. In one specific embodiment, the rib 44 has a width Wless than about one fifth the outer diameter D_(gp) of the grippingportion 41 of the hub 40′ and a peak height H less than about one thirdthe diameter D_(gp). In this particular embodiment, the outer diameterD_(gp) of the gripping portion 41 of the hub 40′ tapers. The peak heightH of the rib 44 is about one third the outer diameter D_(gp) of thegripping portion 41 of the hub 40′ adjacent the second end 22 of thecannula 20. Peak height H is about one fourth the diameter D_(gp), ofthe gripping portion at the other end. Indicator 44 is centered withinthe gripping portion 41, having a length l_(gp) about one half thelength of the gripping portion 41. The shape and dimension of theindicator provides a positive tactile reference through a surgical gloveand yet can be efficiently and inexpensively manufactured.

In one specific embodiment, the hub 40′ had an outer diameter D_(gp) of4/16 inches and a diameter D_(gp) of 3/16 inches. The gripping portion41 of this hub has a length of 9/16 inches and the positive tactileindicator has a length L of 5/16 inches, a width W 1/32 inches and apeak height H of 1/16 inches.

The indicator means of this invention are also useful with other typesof medical needle introducer devices, such as prostate seeding devices,whenever it is important to know the orientation of an aperture. Forexample, a needle introducer 80 is shown in FIGS. 8C-8F that includes alateral aperture 86 at a first end 82. In some embodiments, the end 82forms a piercing point 83 as shown in FIG. 8D. The introducer 80 definesa lumen 85 through the cannula 81 from the first end 82 to a second end83. The lateral aperture 86 is oblong and extends into a portion of thesidewall 81a a of the cannula 81 at the first end. The lumen 85 andfirst aperture 86 are each sized to receive a therapeutic item.

A hub 90 is attached to the second end 83 of the cannula 81 and includesa channel 92 in communication with the lumen 85. The hub 90 includes agripping portion 91 configured to be held when inserting and positioningthe introducer 80. The gripping portion 91 has a length l_(gp),sufficient for gripping. In this embodiment, a positive tactileindicator 95 is disposed along substantially the length l_(gp), of thegripping portion 91 of the hub 90. The indicator has a fixed angularrelationship with the aperture 86 and the piercing point 83.

Referring again to FIG. 1, the cannula 20 of the introducer 19preferably includes a plurality of depth markings 27 located in spacedrelation along the cannula 20. These markings are preferably arranged ingroups of five to give a ready visual indication of the depth ofinsertion of the cannula 20. Where the cannula 20 is composed oftitanium, at least some of the depth markings 27 are preferablyradiographic.

The present invention provides means for protecting the practitionerfrom health risks. In one preferred embodiment, the introducer 15includes a flange 50 projecting from the hub 40 at a locationanatomically distal from the gripping portion 41. The flange 50 isconfigured to prevent inadvertent needle sticks when the practitioner isholding the hub 40 during insertion of a biopsy needle into theintroducer. This is particularly valuable when a biopsy needle isreinserted into the introducer. In light of the attention given to bloodborne diseases in recent years, the need for such features is selfevident. Any size or shape flange is contemplated which will protect thepractitioner's fingers from needle sticks. Preferably, the flange iscircular and extends from the hub at least 15 mm. Most preferably, thecircular flange includes a flattened portion which prevents rolling ofthe device when it is placed on a flat surface. Alternatively, theflange can be hexagonal or octagonal providing many flat sides.

Referring now to FIGS. 8 and 9, the invention contemplates an introducerstylet 55 which includes a shaft 57 and a grip 60. The shaft 57 is sizedto be received within the lumen 25. Preferably, the introducer stylet 55has a length sufficient to block the lateral opening 25 when theintroducer stylet 55 is received within the lumen 25. Most preferably,the introducer stylet 55 has an angled end 58 which is configured tomate with the ramp 35 when the introducer stylet 55 is received withinthe cannula 20. Blocking the lateral opening 24 is important to reducetrauma to the surrounding tissue and preserve the integrity of thesample by preventing tissue from entering the lateral opening 24 as theintroducer is guided into the patient. Trauma can be further reduced byproviding an atraumatic feature, such as bevel 58′, to the end 58 of thestylet 55. The introducer stylet 55 also provides stiffness to theintroducer cannula 20 to facilitate insertion.

The biopsy assembly 10 shown in FIG. 1 includes a hollow biopsy needle11 having an anatomically proximal end 12 and a distal end (not shown).The biopsy needle 11 is sized and configured to be movably, rotatablyand coaxially received within the lumen 25. The proximal end 12 of thebiopsy needle 11 is sized and configured to exit from the lumen 25through the lateral opening 24 as shown in FIG. 4. The biopsy needle 11preferably includes an edge 13 which is configured to pierce tissue toobtain a biopsy sample when the biopsy needle 11 is advanced intotissue.

Any suitable biopsy needle is contemplated. Standard hollow biopsyneedles are preferred, such as Mengehni type. The proximal end 12 ofbiopsy needle 11 includes an edge or tip that may be of any suitableconfiguration. AS shown in FIG. 4 the edge 14 may be blunt. As shown inFIG. 10, the edge 14 may be beveled. The biopsy needle may furtherinclude a needle hub which may include a channel 18 which is preferablyfunnel shaped as described above for the introducer hub 40. The biopsyneedle hub 19 may also include a flattened portion 19A which provides agripping and reference function as described above.

In one embodiment the biopsy needle 11 includes a bend 16 adjacent theproximal end 12 of the needle 11 as shown in FIG. 10. The bend 15deflects the proximal end 12 of the needle 11 at an angle α away from alongitudinal axis 11 of the needle 11 when the bend 17 extends outsidethe cannula 20. The bend 16 increases the diameter of the sampling zoneof the tissue. Multiple samples in a single plane can also be obtainedby providing needles having bends of varying angles and curves. Theangle α is preferably between 5° and 30°. The most preferred angle αbeing about 15°. Where the needle 11 is bent, the ramp 35 may include aconcavely curved surface to facilitate smooth exit of the needle 11through the lateral opening 24.

As shown in FIG. 7, the invention also contemplates a biopsy needlestylet 70. The biopsy stylet 70 facilitates guiding the biopsy needle 11through the lateral opening 24. The biopsy needle stylet 70 includes ahandle 71 and a shaft 75. The handle 71 may include a locking nub 72which mates with a notch (not shown) on the biopsy needle hub 17 forlocking the biopsy stylet into place. The shaft 75 of the biopsy stylet70 is sized and configured to be received within the biopsy needle 11.Preferably, the biopsy needle stylet 70 has a penetrating point 76 thatextends away from the proximal end of the biopsy needle 11 when thebiopsy needle stylet 70 is inserted into the biopsy needle 11. Thepenetrating point 76 aids collection of the sample by piercing thetissue before the tissue is collected within the needle 11. Any suitablyshaped penetrating point is contemplated. For example, penetrating point76 may be rounded or may have a trocar geometry.

Methods of obtaining a biopsy sample are also contemplated by thepresent invention. Preferably, the methods of this invention arepracticed in combination with an imaging study to determine theappropriate needle path to the biopsy sample site. The methods includeproviding a biopsy introducer of the present invention and inserting thebiopsy introducer into the patient at the biopsy sample site usingstandard surgical procedures. Preferably, the methods of this inventionalso include inserting an introducer assembly which includes anintroducer stylet inserted into the cannula. The introducer stylet issized to be received within the lumen and preferably has a length suchthat it will block the lateral opening when the introducer stylet isreceived within the lumen to prevent tissue from entering the lateralopening when the cannula is introduced into the patient. The introducerstylet also provides stiffness to the introducer cannula to facilitateinserting the introducer into tissue. Once the introducer assembly isinserted, the practitioner removes the introducer stylet.

Once the introducer is in place, the invention includes inserting abiopsy needle having an anatomically proximal end and a distal endthrough the aperture and into the lumen of the introducer, advancing thebiopsy needle though the lumen of the proximal end so that the biopsyneedle projects through the lateral opening at an angle relative to theintroducer and into a first biopsy sample site to obtain a first biopsysample, and then withdrawing the proximal end of the biopsy needle fromthe first biopsy sample site and into the lumen of the introducer. As iswell known in the art, a locking member L such as the one shown in FIG.1 can be used to control the depth of the introducer.

The biopsy needle may be provided with a biopsy needle stylet insertedinto the lumen of the hollow biopsy needle. The practitioner will removethe biopsy needle stylet after the biopsy needle has been inserted intothe lumen of the introducer. The biopsy needle stylet provides stiffnessto the hollow biopsy needle which facilitates guiding the needle throughthe lateral opening. Preferably, the stylet includes a penetrating tipwhich pierces the subject tissue as the needle-stylet assembly isadvanced through the lumen of the introducer and into the tissue.

After the stylet is removed, a sample is collected. The sample ispreferably collected by applying suction to the biopsy needle to draw afirst biopsy sample into the biopsy needle through its proximal end.Suction may be applied in any suitable manner. Preferably a syringe willbe attached to the Luer fitting on the hub of the introducer to draw avacuum. Most preferably, the collecting step will also includereciprocating the biopsy needle within the lumen while applying suctionso that the needle edge can help excise the tissue.

This invention contemplates that multiple samples which are cofocal,coaxial and eccentric to the original biopsy sample can be taken in thismanner with only a single placement of the biopsy device. The tissuethat is available to be sampled can be increased by rotating theintroducer to change the exposure of the lateral opening or by alteringthe shape of the biopsy needle.

In one embodiment of the invention, the methods include removing thebiopsy needle from the introducer after withdrawing the biopsy needlefrom the biopsy site, clearing the sample from the biopsy needle,rotating the introducer, reinserting the biopsy needle through theaperture and into the lumen after clearing the sample, further advancingthe biopsy device to eject the proximal end of the biopsy needle fromthe lumen through the lateral opening at the same angle relative to theintroducer to obtain a second biopsy sample from a location eccentricfrom the first biopsy sample, and withdrawing the proximal end of thebiopsy needle from the biopsy sample site into the lumen of theintroducer. Although the biopsy needle is removed from the sample site,the introducer is left in place. Therefore, the practitioner is able toinsert the needle in a precise location relative to the initial samplesite.

Alternatively, the methods may include rotating the introducer with theproximal end of the biopsy needle contained within the lumen and thenfurther advancing the biopsy device to eject the proximal end of thebiopsy needle from the lumen through the lateral opening. A secondbiopsy sample may be obtained from a location eccentric from the firstbiopsy sample. Additional samples may be taken which are cofocal,coaxial and eccentric from the original sample can be taken withoutclearing the sample from the needle.

The methods of this invention also contemplate that the sample siteaccessible to the single biopsy device placement can be broadened byadjusting the angle by which the biopsy needle is deflected from thecannula. This may be accomplished by either providing a second biopsyneedle having a bend adjacent anatomically proximal end of the needle,the bend deflecting the proximal end of the second needle at an angleaway from a longitudinal axis of the second needle or by bending thefirst biopsy needle in a similar manner. The bent needle is similarlyinserted through the aperture and into the lumen and advanced so thatthe proximal end projects through the lateral opening at a differentangle relative to the introducer to obtain a second biopsy sample. Forexample, the second biopsy sample site may be located in a plane definedby the first biopsy sample site and the introducer or may be eccentricto the first site. The invention contemplates rotating the introducerand bending the needle so that the desired tissue location may bereached.

This invention also provides devices and methods for treating lesionslocated within a patient's body. An introducer-guide 100 is shown inFIG. 11. The guide 100 is similar to the introducer 15 shown in FIG. 2.In fact, in some methods it is preferable that the same introducer beused first for diagnosis and then for treatment of a lesion in a singleprocedure. The guide 100 includes a cannula 120 having a first end 121and a second end 122. The cannula 120 defines a lumen 125 which extendsbetween the first end 121 and the second end 122 of the cannula 120 asshown more clearly in FIG. 12. A tip 130 which closes the lumen 125 isdisposed at the first end 121 of the cannula 120. The cannula 120defines an aperture 123 at the second end 122 of the cannula 120. Theaperture 123 is in communication with the lumen 125 is sized andconfigured to receive a therapeutic or diagnostic item for passage intothe lumen 125. It is contemplated that the item could be mechanical,chemical or photo (laser) ablation means, a biopsy needle, a breast masslocalization wire, a radiopharmaceutical composition, such asradioactive seeds, a visualization agent, such as a contrast dye and thelike.

The cannula 120 also defines a lateral opening 124 which is incommunication with the lumen 125. The lateral opening 124 is preferablyadjacent the first end 121 of the cannula 120. The lateral opening 124is sized and configured to allow exit of the item from the cannula as itis advanced through the lumen 125. As described above for the biopsysystem, the introducer 100 preferably includes a ramp 135 disposedwithin the cannula 120 at an end 136 of the lateral opening 124 adjacentthe first end 121 of the cannula 120. The ramp 135 is inclined towardthe lateral opening 124 and provides controlled exit of items exitingthe lateral opening 124.

In the embodiment shown in FIGS. 11 and 12, the lumen is packed withradioactive seeds 130. The seeds 130 can be implanted into an organ,such as the prostate, using conventional procedures which are greatlyaided by the use of the guide 100. One procedure is described in Grimm,1994. Under ultrasound visualization, the guide 100 is inserted into thepatient. In one embodiment, the guide 100 is inserted into the prostateand the seeds 130 are ejected. The guide 100 can then be rotated todirect the lateral opening 124 in another direction.

In a preferred embodiment, the guide 100 is inserted near the prostate.An insertion needle 111 is packed with the seeds 130 and then insertedthrough the lumen 125 of the guide 100 as shown in FIG. 13. As describedabove for the biopsy procedure, the path of the insertion needle 111 canbe adjusted as required to correct a miss-hit or for multiple seed 130placements. Once the guide 100 is properly positioned, it serves as areference point for multiple insertion needle 111 placements.

In some embodiments, the therapeutic item is an ablation means forablating a lesion such as a tumor. In one embodiment depicted in FIG.14, an ablation needle 175 having a cutting edge 176 is provided. Thisdevice can be used for mechanical ablation of small benign lesions suchas arteriovenous malformations. In operation of the device, the guide100 is inserted into the patient with the proximal end 132 as close tothe lesion as possible. The ablation needle 175 is inserted through thelumen 125 and out through the lateral opening 124 to the lesion. Usingthe guide 100, innumerable needle passes can be made through the entirelesion.

In another embodiment, the ablation means is a chemical composition suchas ethanol or cyanoacrylate. Fine-needle alcohol ablation is describedin Karstrup 1990. (See also, Karstrup, et al. Br. J. Radiol 60: 667-670,1987 and Solbiati et al. Radiology 155: 607-6120, 1985). The guide 100of this invention allows precise fine needle placement into multiplelocations with a single guide 100 placement. The cannula 120 of theguide 100 can be adjusted coaxially or rotated to change the directionof the lateral opening 124. Referring now to FIG. 15, a fine needle 140is preferably inserted through the lumen 125 and opening 124 to providesmall controlled doses of ablation agent to multiple locations in thelesion. This invention addresses the need for highly precise placementof the ablation agent. As with the biopsy needle placements describedabove, the introducers of this invention allow extremely precisedelivery without requiring extremely precise introducer placement.

The devices, systems and methods are particularly beneficial when usedin combination with imaging technology, preferably ultrasonography, CTor MR. Precise yet minimally invasive, diagnostic and therapeuticprocedures are possible using this invention under imaging guidance. Thepath of a needle or other object can be guided to an exact location. Theuse of image guided access for biopsy and therapy is discussed inDietrich et al., Suppl. To Diag Imaging, November 1996 and Karstrup etal., Acta Radiological 29: 213-216, 1988.

Although a few embodiments are described here, this invention is notintended to be limited to these systems and procedures. Theintroducer-guides of this invention can be used for placement for anysuitable therapeutic or diagnostic item, particularly where a change indirection from a fixed initial position is desired. For example, thisinvention may also be employed in galactography, or mammary ductcontrast examination. (Diner, AJR 137:853-856, 1981; Tabar et al.,Radiology 149:31-38, 1983; Threatt and Appelman, Radiology 108:71-76,1973.) The present invention is useful in procedures such asgalactography where the most difficult step is proper insertion andpositioning of a needle or other item.

This invention also provides methods of making a guide device. Themethods include: attaching a hub defining a channel to a hollow cannulaand securing an anatomically distal end of a solid tip to the first endof the cannula. The hub is engaged to the cannula by conventionaltechniques such as insert molding. Preferably, the distal end of the tiphas an outer diameter smaller than an inner diameter of the first end ofthe cannula and the securing includes inserting the distal end of saidtip into the first end of the cannula. Preferably, the cannula has avery thin wall. In one embodiment, the securing includes employing amechanical or interference fit, such as crimping the cannula onto thetip. The securing also preferably includes welding. Most preferably, themethods include laser welding or brazing the tip and the cannula afterthe cannula has been crimped into place on the tip. In a preferredembodiment, the cannula is crimped onto the tip so that the ramp formedby the tip is located to ensure that a biopsy needle advancing throughthe lumen does not catch on the portion of the cannula forming thelateral opening. Any methods which provide a smooth transition betweenthe tip and the cannula are contemplated. A smooth transition reducestrauma to tissue during insertion of the device. Any other suitablemethods of securing the tip to the cannula are contemplated includingapplying an adhesive.

The devices of the present invention may be provided in any suitablesize and in any suitable material. For example, in one embodiment, someof the components are made from 300 series stainless steel.Alternatively, some of the components may be composed of titanium orInconel. The hubs of the present invention are preferably made frommolded plastic and similar materials. The size of the components aredictated by the type and location of the tissue to be sampled.

The present invention includes devices and methods that provideextremely precise sampling and/or delivery without requiring extremelyprecise device placements. The invention compensates for peri-siteplacement and accommodates the need for obtaining multiple placementsaround a lesion. The invention also provides safeguards for thepractitioner and the patient.

All publications cited herein are incorporated by reference in theirentirety, as if each were individually incorporated by reference andfully set forth.

While the invention has been illustrated and described in detail in thedrawings and foregoing description, the same is to be considered asillustrative and not restrictive in character, it being understood thatonly the preferred embodiments have been shown and described and thatall changes and modifications that come within the spirit of theinvention are desired to be protected.

1. An introducer guide for introducing medical items into an internaltissue of a patient, comprising: a cannula having a first end and asecond end and defining a lumen therebetween opening at an aperture atsaid second end, said lumen sized to receive the item, said cannuladefining a lateral opening in communication with said lumen adjacentsaid first end, said lumen sized and configured to allow exit of theitem; a ramp disposed within said lumen adjacent and inclined towardsaid lateral opening; and a hub attached to the second end of thecannula, said hub including a gripping portion configured to be heldwhen inserting and positioning the introducer, said gripping portionhaving a length sufficient for gripping, said hub defining a channelhaving a first end and a second end, the first end of the channel incommunication with the aperture for delivering the item to said lumen;and a tactile indicator disposed along substantially the entire lengthof said gripping portion on said hub, said indicator having a fixedangular relationship with said lateral opening.
 2. The introducer guideof claim 1 wherein said tactile indicator is a raised rib.
 3. The guideintroducer of claim 2 wherein said tactile indicator is rounded.
 4. Theguide introducer of claim 2 wherein said rib has a width less than athird of a diameter of said gripping portion of said hub and a heightgreater than said width.
 5. The guide introducer of claim 1 wherein saidtactile indicator is aligned with said lateral opening.
 6. The guideintroducer of claim 1 further comprising a flange projecting from saidhub at a location anatomically distal from said gripping portion.
 7. Theguide introducer of claim 1, further comprising a solid tip having ananatomical distal end secured to the first end of said cannula and aproximal end configured to pierce tissue, said distal end of said tipsloped to form said ramp adjacent and inclined toward said lateralopening.
 8. A method of obtaining a biopsy sample, comprising: providinga biopsy introducer, the introducer having, a cannula having a first endand a second end and defining a lumen therebetween; a tip disposed atthe first end of the cannula and closing the lumen at the first end; thelumen having an aperture at the second end of the cannula, the aperturesized and configured to receive a biopsy needle; the cannula defining alateral opening in communication with the lumen, the lateral openingsized and configured to allow exit of a biopsy needle from the lumen; aramp disposed within the cannula at an end of the lateral openingadjacent the first end of the cannula, the ramp being inclined towardthe lateral opening, whereby a biopsy needle will be deflected throughthe lateral opening as it exits the cannula; and a hub attached to thesecond end of the cannula, the hub including a gripping portionconfigured to be held when inserting and positioning the introducer, thegripping portion having a length sufficient for gripping, the hubdefining a channel having a first end and a second end, the first end ofthe channel in communication with the aperture for delivering the itemto the lumen; and a tactile indicator disposed along the length of thegripping portion on the hub, the indicator having a fixed angularrelationship with the lateral opening; inserting the first end of thecannula into the patient at the biopsy site; tacticallytactilely sensingthe tactile indicator while gripping the hub when the first end of thecannula is inserted into the patient; after tactically tactilely sensingthe tactile indicator, rotating the cannula to orient the lateralopening in a desired direction; inserting a biopsy needle having ananatomically proximal end and a distal end through the aperture and intothe lumen; advancing the biopsy needle through the lumen so that theproximal end of the biopsy needle projects through the lateral openingat an angle relative to the introducer and into a first biopsy samplesite to obtain a first biopsy sample; and withdrawing the proximal endof the biopsy needle from the first biopsy sample site and into thelumen of the introducer.
 9. The method of claim 8, further comprising:removing the biopsy needle from the introducer after withdrawing thebiopsy needle from the biopsy site and while leaving the introducerinserted into the tissue; clearing the sample from the biopsy needle;tacticallytactilely sensing the tactile indicator while gripping thehub; rotating the introducer to orient the lateral opening in a seconddesired direction; reinserting the biopsy needle through the apertureand into the lumen after clearing the sample; further advancing thebiopsy device to eject the proximal end of the biopsy needle from thelumen though the lateral opening at the same angle relative to theintroducer to obtain a second biopsy sample from a location eccentricfrom the first biopsy sample; and withdrawing the proximal end of thebiopsy needle from the biopsy sample site into the lumen of theintroducer.
 10. The method of claim 8, further comprising: tacticallytactilely sensing the tactile indicator and rotating the introducer withthe proximal end of the biopsy needle contained within the lumen andfurther advancing the biopsy device to eject the proximal end of thebiopsy needle from the lumen through the lateral opening at the sameangle relative to the introducer to obtain a second biopsy sample from alocation eccentric from the first biopsy sample; and withdrawing theproximal end of the biopsy needle from the biopsy sample site into thelumen of the introducer.
 11. A method of delivering a therapeutic itemto a pathological site inside a patient's body, comprising: providing aguide introducer, the introducer having: a cannula having a first endand a second end and defining a lumen therebetween; a tip disposed atthe first end of the cannula and closing the lumen at the first end; thelumen having an aperture at the second end of the cannula, the aperturesized and configured to receive an item; the cannula defining a lateralopening in communication with the lumen, the lateral opening sized andconfigured to allow exit of the item from the lumen; a hub attached tothe second end of the cannula, the hub including a gripping portionconfigured to be held when inserting and positioning the introducer, thegripping portion having a length sufficient for gripping, the hubdefining a channel having a first end and a second end, the first end ofthe channel in communication with the aperture for delivering the itemto the lumen; and a tactile indicator disposed along substantially theentire length of the gripping portion on the hub, the indicator having afixed angular relationship with the lateral opening; inserting the firstend of the cannula into the patient at the site; tactically sensing thetactile indicator while gripping the hub and while the first end of thecannula is inserted into the patient; manipulating the cannula whiletactically sensing the tactile indicator to place the lateral openingadjacent the site; and inserting a first item through the aperture andinto the lumen; advancing the first item through the lumen and outthrough the lateral opening at an angle relative to the introducer andinto the site to contact the site with the item.
 12. The method of claim11 15 wherein the item is an ablating chemical composition.
 13. Themethod of claim 11 15 wherein the item is a radiopharmaceuticalcomposition.
 14. The method of claim 11 15 wherein the item is acontrast agent.
 15. The method of claim 11, further comprising: A methodof delivering a therapeutic item to a pathological site inside apatient's body, comprising: providing a guide introducer, the introducerhaving: a cannula having a first end and a second end and defining alumen therebetween; a tip disposed at the first end of the cannula andclosing the lumen at the first end; the lumen having an aperture at thesecond end of the cannula, the aperture sized and configured to receivean item; the cannula defining a lateral opening in communication withthe lumen, the lateral opening sized and configured to allow exit of theitem from the lumen; a hub attached to the second end of the cannula,the hub including a gripping portion configured to be held wheninserting and positioning the introducer, the gripping portion having alength sufficient for gripping, the hub defining a channel having afirst end and a second end, the first end of the channel incommunication with the aperture for delivering the item to the lumen;and a tactile indicator disposed along substantially the entire lengthof the gripping portion on the hub, the indicator having a fixed angularrelationship with the lateral opening; inserting the first end of thecannula into the patient at the site; tactilely sensing the tactileindicator while gripping the hub and while the first end of the cannulais inserted into the patient; manipulating the cannula while tactilelysensing the tactile indicator to place the lateral opening adjacent thesite; and inserting a first item through the aperture and into thelumen; advancing the first item through the lumen and out through thelateral opening at an angle relative to the introducer and into the siteto contact the site with the item; tacticallytactilely sensing theindicator while rotating the cannula; inserting a second item throughthe aperture and into the lumen; and advancing the second item throughthe lumen and out through the lateral opening at the same angle relativeto the introducer to place the item at a location eccentric from thefirst site.
 16. An introducer guide for introducing medical items intoan internal tissue of a patient, comprising: a cannula having a firstend and a second end and defining a lumen therebetween opening at afirst aperture at said first end and a second aperture at said secondend, said lumen sized to receive the item, said cannula defining alateral aperture through a side of said cannula, said aperture sized toand configured to allow exit of the item; a hub attached to the secondend of the cannula, said hub including a gripping portion configured tobe held when inserting and positioning the introducer, said grippingportion having a length sufficient for gripping, said hub defining achannel having a first end and a second end, the first end of thechannel in communication with said second aperture for delivering theitem to said lumen; and positive tactile indicator means for positivelyindicating the direction of said aperture.
 17. The introducer guide ofclaim 16 wherein said positive tactile indicator means includes a raisedrib disposed along said length of said hub, said rib having a fixedangular relationship with said lateral aperture.
 18. The introducerguide of claim 17 wherein said rib has a width less than a third of adiameter of said gripping portion of said hub and a height greater thansaid width.
 19. The introducer guide of claim 18 wherein said lateralaperture is in communication with said first aperture of said cannula toform an oblong aperture.
 20. The introducer guide of claim 19 whereinsaid cannula is a prostate seeding needle.
 21. A hub for a needledevice, the needle device having a cannula having a sidewall with afirst end and a second end, the cannula defining a first aperture and asecond aperture at the second end, the needle defining a lumentherethrough in communication with the first and second apertures, saidhub comprising: a hub body defining a channel having a first end and asecond end, said first end of said channel communicable with the secondaperture of the needle for delivering an item to the lumen of theneedle; a gripping portion on an outer surface of said hub bodyconfigured to be grasped, said gripping portion having a lengthsufficient for gripping; a positive tactile indicator disposed alongsaid length of said gripping portion on said hub, said indicator havinga width less than a third of a diameter of said gripping portion of saidhub and a height greater than said width; and means for fixing said hubto the needle device with said indicator in a fixed angular relationshipto a feature laterally disposed on the cannula.
 22. The hub of claim 21wherein the feature is the first aperture of the needle and the firstaperture is defined in the sidewall of the cannula.
 23. The hub of claim21 wherein the feature is the first aperture of the needle and the firstaperture is oblong and defined at the first end and extending into thesidewall of the cannula.
 24. The hub of claim 21 wherein said positivetactile indicator means includes a raised rib disposed along said lengthof said hub.
 25. The hub of claim 24 wherein said rib has a width lessthan a third of a diameter of said gripping portion of said hub and aheight greater than said width.